Download the survey instrument pdf - 169.3 KB

22 Pages·2007·0.17 MB·English

District: Outletcode:
1
Totalnumberofmedicines -items,rowsfilled Forareasupervisor use
(fillinaftercompleting wholesurveyform)
PART2
ANSWERALLQUESTIONS–IFNORESPONSESTATE“not
PART3
applicable”…or“noresponseobtained”…oranotherreason
1 Date:
2 District
3 County
4 Sub-county
5 Parish
6 Town/village
7 Outletname
8a Istheoutletfrom oneofthesampledparishes orthe YES NO
districtcapital?
8b GPSlocationidentification number: North
FILLALLBOXES
East
9 Typeofoutlet
(code -seetableatbottom ofthispage)
NOTES
10
Parts1,2,34ofthedatacollectionform arecompletedandcorrect– UNITpricecalculations checked
Datacollectornamesandsignatures:
11
1 2
Verification(forms checkedincludingUNIT pricecalculations)
Name
12
Signed: Date:
Coding forquestion9
Publicsector:
1 Publichealthfacility
2 Community-directeddistributors
Privatesector
3 Retailpharmacies (licensedbyNDAwithinlast3years)
4 Drugshops (licensedbyNDAwithinlast3years)
5 Privateclinics/dispensingdoctors
6 Retailstoresandgeneralprovisionsstores, kiosks(fixedstructures)
7 Marketstalls/mobilehawkersandotherinformaldistributionpoints(temporarystructures/mobile)
Not-forprofitsector
8 NGO/missionhealthfacilities
2
13 Nameofowner/managerofthefacility:
(OPTIONAL)
Backgroundofowner/manager: Pharmacist
Pharmacytechnician
theitemslistedtotherightshouldnotbereadout,they
Doctor
14 areforthedatacollectortousetocodetheresponse;
althoughprompts canbemadetoassisttheperson Clinicalofficer/medical
beinginterviewed) assistant
Nurse
Tickone
Nursingassistant(trained)
Otherhealth
other(Specify)
Nameofperson(s)whoprovidedinformationonmedicinepricesand
15
availability
(OPTIONAL)
Backgroundoftheperson Pharmacist
providingtheinformation?
Pharmacytechnician
theitemslistedtotheright Doctor
shouldnotbereadout,theyare
forthedatacollectortouseto Clinicalofficer/medicalassistant
codetheresponse;although
16 Nurse
prompts canbemadetoassist
thepersonbeinginterviewed) Nursingassistant(trained)
Otherhealth
other(Specify)
Tickone
Describemainitemsfor salein Medicines
outlet:
Food
(fortheprivatesectoroutlets)
Softdrinks
theitemslistedtotherightshould Toiletries
notbereadout,theyarefor the
datacollectortousetocodethe Householdgoods
response;althoughprompts can
Alcoholicdrinks
17 bemadetoassisttheperson
beinginterviewed) Mobilephoneairtime
Newspapers
Tickasapplicable
Cosmetics
Cigarettes
Other(specify)
Doyousellmedicines tootherstore-sell(e.g.tootheroutlets,vendors) YES NO
18
3
Wheredoesthe Writenameand/ortickthetypeofoutletthatsourceis
outlet/facilitybuy/obtain
itsanti-malarial Name Wholesaler Pharmacy other
19 medicines from?
(OPTIONAL)
(nameandplaceof
top3)
Howdoyouthe Medicinesrecommended byMinistryofHealth
manager/owner/in-
chargedecidewhich Customer demand
typeofanti-malarial
Mostprofitable
medicinestostock?
Recommended bylocalhealthprofessional
theitemslistedtothe
rightshouldnotbe Specialpurchaseterms offered
readout,theyarefor
Lowestpriced
thedatacollectorto
20 usetocodethe
Drugcompany/rep influence
response;although
prompts canbemade Influenceofthepricingofsame therapeuticgroup
toassisttheperson
beinginterviewed) Locationofpharmacyandtype(wealth)ofcustomer
Countryoforiginofproduct
Tickasapplicable Season diseasepatterns
Other(state)
Ifmorethanoneanti- Recommended byMinistry ofHealth
malarialisstocked,
howdothestaff inthe Customer demand
outletdecide whichto
Mostprofitable
sell/dispense
Personalpreference ofstaffmember
Tickasapplicable Recommended bylocalhealthprofessional
Specialpurchaseterms offered
Lowestpriced
Appearanceofthepatient
21
Fastmovingbrand
Patientawareness/perceptions ofdrugquality andpreferenceforsome
brands/countries oforigin
Patientperceptionthatifpricetoolow,thatmust bepoorquality
Timeoftheday,week,month
Shortshelflife
Drugcompany/rep influence
other(state)
Approximately howmany peopleboughtananti-malarialmedicine yesterday
22
-e.g.1,5,10,20,50,>50
4
Outof patients/customers youservedyesterday,howmanywould yousaydonotbuyafull
23
courseofanti-malarialmedicine e.g.1,2,3,5,6,10
Approximately howmany peopleboughtananti-malarialmedicineinthelastweek
24
-e.g.1,5,10,20,50,>50
Ifthepatientdoesnothaveenough Sellasmanytabletsas havemoneyfor
moneyforthefullcourseofanti-malarial
treatment,whatdoyoudo? Givecredit
Offercheaperalternative
theitemslistedtotherightshouldnotbe
25 readout,theyareforthedatacollectorto Refusetosell
usetocodetheresponse; although
prompts canbemadetoassistthe Referelsewhere
personbeinginterviewed)
other(state)
Tickasapplicable
26 Weretheanti-malarialmedicinesonopendisplay? Alltypes Sometypes None
[OBSERVATION] (vs.hiddenoutofsight) Tick one
Whatareyoursourcesofinformation Ownknowledge
aboutanti-malarial medicines?
Box/leafletwithmedicine
theitemslistedtotherightshouldnotbe
Drugcompanyinformation
readout,theyareforthedatacollectorto
usetocodetheresponse; although
MinistryofHealthguideline
prompts canbemadetoassistthe
27 personbeinginterviewed)
Medicalreferencebook
Tickasapplicable
Workshops,seminars,CME
Media(print,radio,TV)
other(state)
28 Areantibioticsusedtotreatmalaria? YES NO
29 Isco-trimoxazoleusedtotreatmalaria? YES NO
30 Howdocustomers/patients askformedicinesformalaria? bysomething for
malaria/fever
Tickone byaspecificmedicine
name
5
Sales/dispensing
andstorage area
Adequatestorageconditions andhandling ofmedicines -checklist- for
theoutletandtheareawherethemedicines arestored
[A]
1.Thereisamethod inplacetocontroltemperature
(e.g.roofandceilingwithspacebetweenthem inhotclimates).
(1=thereisamethod)
2.Therearewindowsthatcanbeopenedorthereareairvents.
(1=therearewindows)
3.Nodirectsunlightcanentertheareawherethemedicinesarestores
(1=nosunlight)
31
4.Areaisfreefrommoisture(e.g.leakingceiling,roof,drains,taps)
True=1,False=0 (1=nomoisture)
[ASSESSMENT] 5.Medicinesarenotstoreddirectlyonthefloor.
(1=notonfloor)
6.Thereisnoevidenceofpestsinthearea
(1=nopests)
7.Loosetablets/capsulesarenotmanipulated bynakedhand.
(1=nothandled)
8.Premises canbesecuredtopreventtheft
(1=secure)
[A1]=SumofA=
%adequatestorageconditions =([A1]/8)x100
Pleaseprovideadescription oftheenvironment wherequestion31doesnotadequately
describethesituation.
32
[OBSERVATION]
[Optional]
Wasthe patientpackofCoartemavailable) –i.e.the6,12, YES NO
33
18,24packs withspecialpatientinstructions (shouldalsobe
[OBSERVATION]
marked asavailableinpart3)
6
Doestheoutletsell/provide TBmedicines? YES NO
34
If yesto#34 -theoutletsells/providesTBmedicines,askquestions35-40–otherwiseENDofpart1:
Howdoyouthe Medicinesrecommended byMinistryofHealth
manager/owner/in-charge
decidewhichtypeofTB Customer demand
medicines tostock?
Mostprofitable
Theitemslistedtotheright
Recommended bylocalhealthprofessional
shouldnotbereadout,they
areforthedatacollectorto Specialpurchaseterms offered
usetocodetheresponse;
althoughprompts canbe Lowestpriced
35 madetoassisttheperson
beinginterviewed Drugcompany/rep influence
Influenceofthepricingofsame therapeuticgroup
Tickasapplicable
Locationofpharmacyandtype(wealth)ofcustomer
Countryoforiginofproduct
Seasondiseasepatterns
Other(state)
Approximatelyhowmany peopleboughtTBmedicineyesterday
36
-e.g.1,5,10,20,50,>50
Outofpatients/customers youserved yesterday,howmanywould yousaydidnotbuya
37
fullcourseofTBtreatment e.g.1,2,3,5,6,10
Approximately howmany peopleboughtTBmedicineinthelastweek
38
-e.g.1,5,10,20,50,>50
Whatareyoursourcesof Ownknowledge
informationaboutTB
medicines? Box/leafletwithmedicine
Drugcompany information
Theitemslistedtotheright
shouldnotbereadout,they
MinistryofHealthguideline
areforthedatacollectorto
39
usetocodetheresponse; Medicalreference book
althoughpromptscanbe
madetoassisttheperson Workshops,seminars, CME
beinginterviewed
Media(print,radio,TV)
Tickasapplicable
Other(state)
Howdocustomers/patients askforTBmedicines?
Tickone bysomething for
40 TB/persistentcough
byspecific medicinename
7
Part 2
Genericname, Medicine Brandor Manufacturer Total Available Packsize Pack Priceof Unit Total Any Comments
dosageform, Type product numberof 1/0 recomme size pack price(4 number expired
strength name(s) generic nded found found digits) packs (1/0)
versionon found
shelf
Highest 10
Amitriptyline price
25mgcap/tab LowestPrice 10
Highest 15
Amoxicillin price
500mgcap/tab LowestPrice 15
Highest 28
Atenolol50mg price
cap/tab LowestPrice 28
Highest 10
Captopril25mg price
cap/tab LowestPrice 10
Highest 1
Ceftriaxone price
1g/vialinjection LowestPrice 1
Highest 10
Ciprofloxacin price
500mgcap/tab LowestPrice 10
Highest 100ml
Co-trimoxazole price
8+40mg/ml
LowestPrice 100ml
suspension
Highest 10
Diazepam 5mg price
cap/tab LowestPrice 10
Highest 1
Diclofenac price
50mgcap/tab LowestPrice 1
8
Medicine Brandor Manufacturer Total Available Packsize Pack Priceof Unit Total Any Comments
Genericname, Type product numberof 1/0 recomme size pack price(4 number expired
dosageform, name(s) generic Nded found found digits) packs (1/0)
strength versionon found
shelf
Highest 30
Glibenclamide price
5mgcap/tab LowestPrice 30
Highest 20
Omeprazole price
20mgcap/tab LowestPrice 20
Highest 100ml
Paracetamol price
24mg/ml
LowestPrice 100ml
suspension
Salbutamol Highest 1Cannister Unitprice=1dose
inhaler price (200doses)
0.1mg/dose LowestPrice 1Cannister Unitprice=1dose
inhaler (200doses)
Highest 30
Simvastatin price
20mgcap/tab LowestPrice 30
9
IftheoutletstocksTBmedicines
Genericname,dosage Medicine Brandor Manufacturer Total Available Packsize Pack Priceof Unit Total Any Comments
form,strength Type product numberof 1/0 recomme size pack price(4 number expired
name(s) generic Nded found found digits) packs (1/0)
versionon found
shelf
Isoniazid(INH)100 Highest
mgtab/cap price
LowestPrice
Isoniazid(INH) 300 Highest
mg tab/cap price
LowestPrice
Rifampicin150mg Highest
tab/cap price
LowestPrice
Rifampicin300mg Highest
tab/cap price
LowestPrice
Ethambutol(EMB) Highest
400mgtab/cap price
LowestPrice
Pyrazinamide(PZA) Highest
400mg tab/cap price
LowestPrice
Isoniazid/ Ethambutol Highest
150mg/400mg price
tab/cap LowestPrice
Rifampicin/ Highest
Isoniazidtab/cap price
150mg/75mg LowestPrice
Rifampicin/Isoniazid Highest
tab/cap: price
300mg/150mg LowestPrice
Rifampicin/Isoniazid/ Highest
Pyrazinamide/ price
Ethambutoltab/cap:
LowestPrice
150mg/75mg/400mg/
275mg
10
Part 3
Genericname,dosageform, Brandname Manufacturer Available Packsize Pack Priceof Unit Total# Any Comments
strength 1/0 recomm- size pack price(4 packs expired
Ended found found digits) found 1/0
Amodiaquine Loquin MedriechSterilab 60ml
50mg./5mloralsuspension 001
Amobine Regal 60ml
002
Camoren ReneIndustries 60ml
003
Amodiaquine Uniquin Pharmaceutical 8
200mgtablet 004 ManufacturingCo.(K)
Maratab LincolnPharmaceuticals, 8
005
Amoquine AgogPharma 8
(thane) 006
Loquin MedriechSterilab 8
007
Betaquine BetaHealthcare 8
008 International
Amodiaquine UgandaPharmaceuticals 8
009
Camoren ReneIndustries 8
010
Amobin RegalPharmaceuticals 8
011
Genericname,dosageform, Brandname Manufacturer Available Packsize Pack Priceof Unit Total# Any Comments
strength 1/0 recomm- size pack price(4 packs expired
Ended found found digits) found 1/0
Artemether Larither IpcaLaboratories 12
40mgcapsule 012
Artemether Artesiane Rotexmedica 1
100mg/mlinjection 013
Rtitas Intas 1
014
Artenam EbewePharma 1
015
Artemether Artesiane RotexmedicaGmbh 1
20mg/mlinjection 016
Artena EbewePharma 1
paediatric
017